Advanced Paediatric Life Support Guidelines Research Articles

Validation of three age based weight formulae for estimating weight among Indian children

Background: Weight estimation in paediatric emergencies is often required to calculate drug dosages, fluid therapy and defibrillation. The ‘gold standard’ of actually weighing the patient is not practically possible in emergency conditions. Many formulae have been developed in an attempt to accurately estimate a child’s weight using age like advanced paediatric life support (APLS), Luscombe, and Argall’s modification. However, these formulae might not be applicable in the Indian context. This study aims is to validate standard age-based formulae (APLS, Luscombe, and Argall’s) and their accuracy in estimating the weight of Indian children. Methods: The study used secondary data from the fourth round of the National Family Health Survey (2015-16). The estimated weights as computed by the APLS guidelines, the Luscombe and the Argall formulae were compared to their respective measured weights during the survey. Results: All three formulae (APLS, Luscombe, and Argall) overestimated the weights. The APLS formula exhibited the least weight difference among the different age groups (-3.51±2.08 kg). The average percentage difference between the estimated weights using the APLS, Luscombe, and Argall formula and the actual weights was 23%, 38%, and 28%, respectively. Conclusions: All the three age-based weight formulae, namely APLS, Argyll, and Luscombe, overestimated the weight among the Indian children, clearly showing the need to adjust the formulae for accurate weight estimation of Indian children.

The relative position of femoral artery and vein in children under general anesthesia--an ultrasound-guided observational study.

Femoral artery overlaps femoral vein by varying degrees distal to the inguinal ligament, which may result in difficult venous access and also increases the risk of arterial puncture. To study the size of femoral vessels and the degree of overlap in children undergoing anesthesia using ultrasound at 1 and 3cm distal to inguinal ligament. A prospective observational study, 84 children aged <7years were recruited in six different age groups. An experienced anesthetist identified the femoral vessels and their overlap using ultrasound at two fixed points distal to the inguinal ligament. We also evaluated the correlation of skin puncture site marked as per Advanced Paediatric Life support (APLS) guidance using landmark technique with the ultrasound location of femoral vein beneath the same site. The percentage of children with overlap of femoral vein by femoral artery increases from 5% to 60% as we move distal to the inguinal ligament. At 3cm distal to inguinal ligament, the incidence of any degree of overlap was statistically significant (P<0.05) in children <5years. In 80% of children, the femoral vein was located by ultrasound beneath the skin puncture site as recommended by APLS guidelines. A significant increase in femoral vein overlap occurs as we move distal to the inguinal ligament. There is one in five chance of failure to locate femoral vein by landmark technique. In children <2years, a high approach to femoral vein cannulation under ultrasound guidance is recommended.

How to use capillary refill time

Capillary refill time (CRT) is defined as the time taken for colour to return to an external capillary bed after pressure is applied to cause blanching.1 It was first described...

G87 How Much Do Junior Doctors Know About Anaphylaxis?

Anaphylaxis is a severe, life-threatening hypersensitivity reaction. NICE issued guidance in December 2011 regarding management of suspected anaphylaxis, the authors of which attribute suboptimal management to inadequate understanding by health...

Emergency management of paediatric status epilepticus in Australia and New Zealand: Practice patterns in the context of clinical practice guidelines

To establish current acute seizure management through a review of clinical practice guidelines (CPGs) and reported physician management in the 11 largest paediatric emergency departments in Australia (n= 9) and New Zealand (n= 2) within the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network, and to compare this with Advanced Paediatric Life Support (APLS) guidelines and existing evidence. (i) Review of CPGs for acute seizure management at PREDICT sites. (ii) A standardised anonymous survey of senior emergency doctors at PREDICT sites investigating management of status epilepticus (SE). Ten sites used seven different seizure CPGs. One site had no seizure CPG. First line management was with benzodiazepines (10 sites). Second line and subsequent management included phenytoin (10), phenobarbitone (10), thiopentone (9), paraldehyde (6) and midazolam infusion (5). Of 83 available consultants, 78 (94%) responded. First line management of SE without intravenous (IV) access included diazepam per rectum (PR) (49%), and midazolam intramuscular (41%) and via the buccal route (9%). First line management of SE with IV access included midazolam IV (50%) and diazepam IV (44%). The second line agent was phenytoin (88%); third line agents were phenobarbitone (33%), thiopentone and intubation (32%), paraldehyde PR (22%) and midazolam infusion (6%). Fourth line agents were thiopentone and intubation (60%), phenobarbitone (16%), midazolam infusion (13%) and paraldehyde (9%). Initial seizure management by CPG recommendations and reported physician practice was broadly similar across PREDICT sites and consistent with APLS guidelines. Practice was variable for second/third line SE management. Areas of controversy would benefit from multi-centred trials.

Prospective cohort study to test the predictability of the Cardiff and Vale paediatric early warning system

Objective:To develop and test the predictability of a paediatric early warning score to identify children at risk of developing critical illness.Design:Prospective cohort study.Setting:Admissions to all paediatric wards at the University...

New formulae for predicting tracheal tube length

The aim of this study was to determine the accuracy of standard techniques for estimating oral and nasal tracheal tube length in children and to devise more accurate predictive formulae that can be used at the bedside. Data were collected from 255 children who required tracheal intubation whilst on the Pediatric Intensive Care Unit over a period of 1 year. Age, weight, the final length of the tracheal tube and the internal diameter were documented. Patients with a tracheostomy were excluded from the study. Using linear regression the following formulae best predicted final tracheal tube length. For children over 1 year of age: Insertion depth (cm) for orotracheal intubation = age/2 + 13 Insertion depth (cm) for nasotracheal intubation = age/2 + 15 For children below 1 year of age: Insertion depth of orotracheal tube (cm) = weight/2 + 8 Insertion depth of nasotracheal tube (cm) = weight/2 + 9 Current Advanced Paediatric Life Support guidelines underestimate the appropriate tracheal tube lengths for orotracheal intubation in children over 1 year of age. Similarly, the novel weight-based formulae for tracheal tube lengths in children below the age of 1 year proved more accurate than standard reference charts. We therefore recommend that these new formulae are prospectively evaluated.

Withdrawal of parenteral phenobarbitone--implications for resource-poor countries.

Parenteral phenobarbitone is an integral part of the management of status epilepticus, especially in the context of resource-poor countries. It is highly effective at controlling seizures. It is safe, cheap, can be given by rapid intravenous push or intramuscular route, boluses can be repeated, and it is recommended as part of the Advanced Paediatric Life Support guidelines. The proposed alternatives lack efficacy, practicality and/or place the child in status epilepticus at risk of respiratory compromise. The impact of the loss of parenteral phenobarbitone would be increased cardiac complications, lack of early seizure control, prolonged seizures resulting in brain damage and systemic complications. Increased numbers of patients will require artificial ventilation in centres without facilities, and centres with facilities will be unable to cope with the load of ventilated patients because of lack of safe transport systems and bed space.

Inappropriate emergency management of status epilepticus in children contributes to need for intensive care

Objectives: To characterise the clinical features, emergency pre-paediatric intensive care (PIC) treatment, and course of status epilepticus (SE) in children admitted to PIC. This may provide insight into reasons for...

Admissions for critically ill children: where and why?

Planning services for critically ill children requires identification of overall critical care activity as well as an assessment of population needs. METHOD AND OBJECTIVES: This prospective needs assessment took a census approach to estimating population-based admission rates for paediatric critical care irrespective of where care was provided. A survey form was completed for every child in the study population for all of their admissions. The need for tracheal intubation was used as a proxy for defining need for intensive care in this study. Critical illness was defined by clinical criteria adapted from the Advanced Paediatric Life Support Guidelines. All children under 17 years resident in south-east England (Thames regions) who required care for a critical illness in any inpatient setting between 1 December 1996 and 30 November 1997. Critical illness was the presence of acute body-system or multi-system failure. A wide variation in the rates of critical care admission to different types of care settings was reported ranging from 1.2 admissions per 1000 resident children per year for PIC units (general and cardiothoracic units) to 0.02 admissions per 1000 children per year for children admitted from the community to neonatal units. The age of children and their rates of admission were directly related to the type of ward or unit where children received care. Tracheal intubation occurred in all care settings. The proportion of intubated children transferred to paediatric intensive care units (PICUs) or paediatric cardiothoracic intensive care units (PCICUs) varied according to the type of referring unit. The proportion of episodes involving tracheal intubation where the child was not transferred to a PICU or PCICU was 52% for children in stand-alone neurosurgical units, 41% for those in adult intensive care units (AICUs), and 4% for those in children's wards. This baseline study shows a significant number of critically ill children who are never cared for in PIC units. With national changes in UK policy to regionalise care for these children, monitoring care in all locations by cause of admission remains important. While the data were collected in 1997, the findings from this study remain relevant and provide the basis for planning regional critical care services for children. Results are also relevant to other geographical areas in that measuring the use of services for critically ill children must go beyond documenting admission to ICUs for children and adults. All settings for critical care must be identified, the activity documented, and the use of services measured against existing resources. Clear clinical criteria are needed to identify children who can be cared for appropriately on high dependency units.